Medicaid Buy-In Program for Working People With Disabilities (MBI

STATE OF NEW YORK
DEPARTMENT OF HEALTH
Corning Tower
The Governor Nelson A. Rockefeller Empire State Plaza
Antonia C. Novello, M.D., M.P.H., Dr.P.H.
Commissioner
Dennis P. Whalen
Executive Deputy Commissioner
ADMINISTRATIVE DIRECTIVE
TO:
Albany, New York 12237
TRANSMITTAL:
Commissioners of
Social Services
DIVISION:
DATE:
04 OMM/ADM-5
Office of Medicaid
Management
July 20, 2004
SUBJECT: Medicaid Buy-In Program for Working People With Disabilities (MBIWPD): Transition of the MBI-WPD Program to Local District Staff
SUGGESTED
DISTRIBUTION:
CONTACT
PERSON:
ATTACHMENTS:
Medicaid Staff
Fair Hearing Staff
Staff Development Coordinators
Bureau of Local District Support
Upstate: (518) 474-8216
NYC:
(212) 268-6855
Attachment I
–
Attachment II –
Attachment III –
Attachment
Attachment
Attachment
Attachment
IV
V
VI
VII
–
–
–
Explanation of the MBI-WPD Program
Grace Period Request Form
Sample Grace Period Letter For Medical
Condition)
Sample Grace Period Letter For Job Loss
Acceptance Notice (manual) – English
Acceptance Notice (manual) – Spanish
MBI-WPD Monthly Report Form
FILING REFERENCES
Previous
ADMs/INFs
03 ADM-4
95 ADM-17
Releases
Cancelled
Dept. Regs.
Soc. Serv. Manual Ref. Misc. Ref.
Law & Other
Legal Ref.
GIS 04 MA/009
366(1)(a)(14) MRG pp.
GIS 04 MA/004
&(15)
65-67
GIS 03 MA/009
178-79
GIS 01 MA/036
367-a(15)
195-98
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 2
320
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 3
I. PURPOSE
The purpose of this Administrative Directive is to provide Local
Departments of Social Services (LDSS) with the plan for transition of
eligibility determinations and full data entry for the MBI-WPD program to
LDSS staff effective July 1, 2004.
Sections 62-69 of Part A of Chapter 1 of the Laws of 2002 established the
Medicaid Buy-In program for Working People with Disabilities (MBI-WPD) that
extends Medicaid coverage to working applicants/recipients (A/Rs) with
disabilities who have net incomes at or below 250% of the Federal Poverty
Level (FPL) and non-exempt resources at or below $10,000.
Administrative Directive (ADM) 03 OMM/ADM-4, issued on June 9, 2003,
advised LDSS of the interim implementation plan for the MBI-WPD program
that began July 1, 2003. Under the interim plan, eligibility
determinations have been made by staff at the New York State Department of
Health. There has been no systems support for automated premium collection
and tracking; therefore, a moratorium on premium payment has been in
effect. Because the automated Premium Payment Collection and Tracking
(PPCT) system is not yet operational, the moratorium on premium collection
continues. Once the PPCT system is operational, further instructions will
be forthcoming.
II.BACKGROUND
Chapter 1 of the Laws of 2002 enacted two new categorically needy Medicaid
groups under the MBI-WPD program in New York State, by adding two new
subparagraphs (12) and (13) to Section 366.1(a) of the Social Services Law
(SSL). A new subdivision (12) to Section 367-a of SSL provides for the
payment of premiums for certain participants based on net available income.
The MBI-WPD program is intended as a work incentive for persons with
disabilities (including blindness).
Since July 1, 2003, LDSS staff and the Inter-Agency Team (IAT) at the
Office of Medicaid Management (OMM) Albany Central Office (ACO) have shared
responsibility for implementation of the MBI-WPD program (see 03 OMM/
ADM-4). LDSS staff accepts applications and performs undercare and recertification functions and ACO staff performs eligibility determinations
and full data entry. On July 1, 2004 the responsibility for implementation
of the MBI-WPD program, including eligibility determinations and full data
entry for new cases and spenddown conversion cases, will transition to the
LDSS.
Negotiations with a vendor are underway to provide premium collection and
tracking for the MBI-WPD program but the contract will not be complete at
the time the transition takes place. Therefore, the moratorium on premium
payment and tracking continues.
III.PROGRAM IMPLICATIONS
A.
Eligibility Requirements for the Medicaid Buy-In Program for Working
People with Disabilities: Two Groups
As stated in 03 OMM/ADM-4, effective July 1, 2003, two new
eligibility groups were established for the MBI-WPD program: the
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 4
Basic Coverage group and the Medical Improvement group. To be
eligible for either group, an A/R must have a disability that meets
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 5
the medical criteria for Supplemental Security Income (SSI)
established by the Social Security Administration (SSA) but have too
much income to qualify for SSI.
Basic Coverage Group
In addition to the usual Medicaid rules, the requirements that apply
to the Basic Coverage group are:
•
•
•
•
•
•
Age - The A/R must be at least 16 years of age, but under the
age of 65.
Work – The A/R must be engaged in a work activity for which
they receive financial compensation and pay all applicable
state and federal income and payroll taxes (see Required Action
section for verification of Sheltered Workshop employees work).
Disability – The A/R must have certification of disability.
Income – The A/R must have total net income at or below 250% of
the FPL. If net income is at or above 150% of the FPL but does
not exceed 250% of the FPL, a premium payment will be required.
Note: SSI-related budgeting, including allocation and deeming,
is used for determining net available income and resources.
Resources – Non-exempt resources cannot exceed $10,000.
Premium Payment - The premium is 3% of net earned income plus
7.5% of net unearned income (after SSI-related budgeting
methodology is applied). Individuals with net income below
150% of the FPL pay no premium.
Note: A moratorium on premium payments is effective until such
time as systems support for an automated premium collection and
tracking become available.
Medical Improvement Coverage Group
In addition to the usual Medicaid rules, the requirements that apply
to the Medical Improvement group are:
•
•
•
•
A new applicant is NEVER placed in the Medical Improvement
Group. The individual must first be in receipt of coverage
through the Basic Group and lose eligibility for that group as
a direct and specific result of medical improvement (see
Disability requirement below).
Age - The A/R must be at least 16 years of age but under the
age of 65.
Work – The A/R must be engaged in a work activity for which
financial compensation is received and all applicable state and
federal income and payroll taxes are paid (see Required Action
section for verification of Sheltered Workshop employees work).
A recipient in the Medical Improvement Group must be employed
at least 40 hours per month and earn at least the federally
required minimum wage.
Disability – The recipient’s disability determination
(performed by the State Disability Review Team in Albany as a
Continuing Disability Review) indicates that the individual is
no longer disabled but retains a severe medically determined
impairment.
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
•
•
•
Page No. 6
Income – The A/R must have a total net income that is at or
below 250% of the FPL. If net income is at or above 150% of
the FPL but does not exceed 250% of the FPL, a premium payment
will be required.
Note: SSI-related budgeting, including allocation and deeming,
is used for determining net available income and resources.
Resources – The A/R’s non-exempt resources cannot exceed
$10,000.
Premium Payment - The premium is 3% of the net earned income
plus 7.5% of net unearned income (after SSI-related budgeting
methodology is applied). Individuals with net income below
150% of the FPL pay no premium.
Note: A moratorium on premium payments is effective until such
time as systems support for an automated premium collection and
tracking is available.
B. Managed Care
MBI-WPD applicants who wish to participate in Managed Care may opt to
enroll if their net income is less than 150% FPL. MBI-WPD participants
with income between 150% and 250% FPL are excluded from Managed Care
even in districts with mandatory Managed Care programs.
C. Cost Shares
Cost shares for MBI-WPD participants will be at the regular cost share
rate of 50% federal, 25% State and 25% local, and 50% federal, 40% State
and 10% local for Long Term Care costs, with no local administrative
costs. Local districts must use the revised schedule D-4 to claim
administrative costs for the MBI-WPD program.
D. Premium Payment Collection and Tracking (PPCT) System:
Subsystem
A New WMS
A new Welfare Management System (WMS) subsystem is under development to
hold data specific to premium collection and tracking for the MBI-WPD
program. A systems interface is also under development to supply
necessary information to the selected Premium Payment Collection and
Tracking System vendor, who will be responsible for mailing premium
bills/coupons, some notices and letters and for the necessary tracking
functions for the MBI-WPD program. Once the automated PPCT system is
operational, the contracted PPCT system vendor will report to the OMM
and LDSS according to a prearranged schedule. Information regarding
this system will follow at a later date.
E. Application Process
This section addresses application forms, the face-to-face interview and
coverage codes for the MBI-WPD program.
Application Forms
The following application forms are accepted for the MBI-WPD program:
• LDSS-2921 “Application for Public Assistance/Medical
Assistance/Food Stamps/Services”
• Medicaid Renewal (Recertification) Form
• Access New York Health Care Form DOH-4220
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 7
Local district staff is reminded that an MBI-WPD application form,
whether the applicant is new or currently on spenddown, must be
accompanied by current documentation of items subject to change, such as
employment. If an applicant is currently on spenddown, the client’s
most recent application or renewal form will be accepted as long as it
was filed within the last six months. If it has been more than six
months since the application was completed, a new form must be
submitted.
Face-to-Face Interview
The LDSS must schedule and conduct the face-to-face interview with the
applicant or his/her representative and during the interview:
•
•
•
•
Discuss the availability of Impairment Related Work Expenses
(IRWEs) deductions and Plan for Achieving Self-Support (PASS)
accounts with the A/R.
Provide the applicant with a copy of the “Explanation of the MBIWPD Program” (see Attachment I of this ADM).
Verify age, work and disability status (see Required Actions for
each of these requirements).
Determine if disability certification is needed. If a disability
determination is needed, local district staff must request medical
documentation from the applicant’s medical providers (see Required
Actions for disability determinations process).
Coverage Codes That Apply Based on Resource Documentation
The August 2004 systems migration for Attestation of Resources will
include new coverage codes that will apply to the MBI-WPD program based
on resource documentation provided. These coverage codes will appear in
a separate ADM that will be released in the near future. See the
Systems Implications section of this ADM for coverage codes that apply
until attestation of resources is implemented.
IV.REQUIRED ACTION
As of July 1, 2004, the LDSS will be responsible for implementation of the
MBI-WPD program. The application process will continue as directed in the
Interim Implementation plan; however, as stated in GIS MA/004, the Access
New York Health Care form DOH-4220 or the CNS generated Medicaid Renewal
(Recertification) Form, if completed within six months of the request for
participation in the MBI-WPD program, may now be used in addition to the
LDSS-2921 “Application for Public Assistance/Medical Assistance/Food
Stamps/Services” form. The face-to-face interview continues to be a
requirement of application as does verification of the specific eligibility
requirements.
A. Age Requirement
An applicant for the
but under the age of
age or older, she/he
Documentation of age
MBI-WPD program must be at least 16 years of age,
65. If the applicant is under 16 or 65 years of
is not eligible for the MBI-WPD program.
is necessary at the time of application or renewal.
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 8
If the A/R’s 65th birthday occurs within 12 months of the date of
application or renewal, coverage under the MBI-WPD program must end on
the last day of the month of the individual’s 65th birthday. The worker
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 9
must discuss this with the individual at the time of application or
renewal and shorten the authorization period accordingly.
B. Work Requirement
If an applicant is not currently working, LDSS staff should offer a
referral to VESID or to a Benefits Planner. Until the applicant is
working, he/she cannot participate in the MBI-WPD program and must
instead be evaluated for Medicaid under other programs, such as
spenddown.
Acceptable proof of work includes an A/R’s: current pay stub(s), pay
check(s) or a written statement from the employer. When these are not
available the A/R’s income tax return, W-2 form, or records of bank
deposits may be used.
Sheltered Workshop
03 OMM/ADM-4 states that, “the A/R must be engaged in a work activity
for which they receive financial compensation and pay all applicable
state and federal income and payroll taxes.” However, some sheltered
workshop employees are tax blocked and for these individuals, although
they may have pay stubs or a detailed statement of earnings from their
employer, taxes are not deducted from their pay. In this case the tax
requirement is not applicable and the pay stubs or employer’s detailed
statement of work may be used to verify work. In these instances the
detailed statement of earnings from the employer or current pay stubs is
considered acceptable proof of work.
Self-Employment
The Medicaid Reference Guide (MRG) may be used for guidance regarding
self-employment verification. The MRG contains information on
verification of small business, farm income, partnerships and
corporations, as well as instructions for estimating net earnings from
self-employment and determining net profits. Applicants for the MBI-WPD
program who are self-employed in their own business are not required to
show a profit but must submit documentation as detailed in the MRG.
Grace Periods
A grace period is a time period during which a MBI-WPD program
participant is not working but remains eligible for the program. Grace
periods are a way of recognizing the fact that persons with disabilities
may have periods of increased or decreased ability to work for medically
verifiable or other reasons that require special consideration.
Recipients may be granted multiple grace periods during a 12-month
period; however, in no event may the sum of the grace periods exceed six
months in the 12-month period.
Two types of grace periods may be granted:
1. Change in Medical Condition: A grace period of up to six months
will be allowed if, for medical reasons, the MBI-WPD participant
is unable to continue working. Medical verification will be
required. When an applicant requests this type of grace period,
LDSS must request medical verification.
2. Job Loss (through no fault of participant): A grace period of up
to six months will be allowed if, through no fault of the
participant, job loss is suffered i.e., due to layoff, etc.
Verification is required. Districts must verify that the
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 10
recipient is reasonably expected to return to employment, for
example, a temporary layoff, or that the recipient is actively
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 11
seeking new employment. An individual who is in receipt of
unemployment insurance, who was let go from a job related to
behavior resulting from the individual’s disability, is considered
eligible for a job loss grace period as the individual lost
employment through no fault of their own. Receipt of unemployment
insurance implies that the individual is actively seeking new
employment.
Note: MBI-WPD participants reporting job loss due to non-medical
reasons should be referred to One-Stop Centers, Vocational and
Educational Services for Individuals with Disabilities (VESID) and
Benefits Planning Assistance & Outreach (BPA&O) services as
applicable, so that assistance with employment may be sought prior
to loss of eligibility in the program.
If an individual loses eligibility for the MBI-WPD program due to job
loss or medical condition that exceeds the six-month allowable grace
period, the individual may reapply for the program without completing a
new application form for up to 30 days following discontinuance.
However, verification of return to work is needed.
The current process for grace periods, which will carry over for the
transition, is as follows:
•
•
•
•
•
A recipient must complete a MBI Grace Period Request form (see
Attachment II to this ADM).
The recipient must return the form with the required documentation
to the LDSS.
The required documentation must support the request for a grace
period by detailing why the recipient is out of work and how long
they will be out.
o Change in medical condition supporting documentation must
detail the current health problem, treatment and the time
period that the recipient will be out of work. It must be
provided by a Medical Doctor or primary care practitioner.
o Job Loss documentation includes a layoff notice or a
statement from the Department of Labor, VESID, etc.
Each grace period request is reviewed along with the supporting
documentation.
o The grace period is approved by the LDSS for the time period
requested by the recipient, unless the approval would result
in the recipient exceeding the six-month maximum grace
period. Remember, the 12 month tracking period for grace
periods starts with the first day of the first awarded grace
period. At the end of the 12 months, a new 12 month
tracking period starts. The 12 month tracking period is
independent of the authorization period and is not tied to
the authorization period.
The signed notice of decision is sent to the recipient. The LDSS
must return the completed request form to the recipient within 10
working days.
Two model notices, one for each type of grace period, are included as
Attachments III and IV of this ADM. One of these letters should be sent
to a recipient when the district sends the signed grace period decision
to the recipient. The letters inform the recipient of the necessary
steps that will be required of them as the grace period draws to a
close.
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 12
Beginning July 1, 2004 local districts will need to keep track of grace
periods by either using a “tickler file” or database to make sure the
recipient doesn’t exceed the six month grace period limit. The Office
of Medicaid Management has a database that may be used for this purpose.
If your district would like a copy of this database, you may e-mail a
request to:
[email protected]
C. Disability Requirement
Proof of Disability
Applicants must provide proof of disability. Acceptable proof of
disability for initial application in the MBI-WPD program include:
•
•
An award letter from the Social Security Administration for Social
Security Disability Insurance (SSDI) benefits or other proof of
receipt of SSDI benefits, such as a check or bank deposits listing
the benefit. A Medicare card is also considered acceptable proof.
An existing State or Local Disability Review Team certification at
initial application for the MBI-WPD program.
Note: If the individual does not have existing certification of
disability at the time of initial application, a disability
determination must be performed by the State Disability Review
Team in Albany.
New Disability Determinations
Local districts are reminded of their continuing responsibility to
assist an A/R in establishing proof of disability or continuing
disability. Medicaid applicants with an alleged disability, who are
working and earning Substantial Gainful Activity (SGA) must be
considered for a disability determination and informed of the MBI-WPD
program. It is not appropriate to exclude these individuals from the
first step of the sequential evaluation for disability.
If an individual is working and alleges a disability but does not have
acceptable proof of disability, the LDSS must:
•
•
Discuss the MBI-WPD program with the individual and give them the
written explanation of the program.
Have the individual sign the appropriate release of medical
documentation forms.
Note: During the interim implementation period, counties
requested that medical providers send evidence directly to the
Albany Central Office. Beginning July 1, 2004, medical evidence
is to be sent to the local district. The letter requesting
medical evidence from treating sources should be modified to
include the appropriate local district address to insure that
medical evidence is sent to the local district and not to the
Albany Central Office. Only a complete disability package will be
sent to the State Disability Review Team in Albany. In the case
of No Actions, the LDSS will be sent the completed DSS-639 with
details of medical documentation needed. The district must make
every effort to assist in obtaining the requested information and
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 13
carefully document the efforts in the applicant’s file. If the
medical provider is unwilling or unable to provide the requested
Date:
July 20, 2004
Trans. No.
•
•
•
•
•
04 OMM/ADM-5
Page No. 14
documentation, a consultative exam will be required (see
Consultative Exam section below). If the requested documentation
is not received after several attempts or if the applicant fails
to comply with two consultative examination dates, the local
district will deny the MBI-WPD application for failure to provide
documentation.
Note: It is important that attempts to obtain medical
documentation and contacts with the applicant regarding
consultative examination dates be carefully documented by local
district staff.
Complete the DSS-1151 interview form during the face-to-face
interview and create a list of all treating sources (physicians,
psychologists, hospitals, therapists, counselors, etc.).
Utilize the DSS-486T forms and a copy of the release of medical
evidence form to obtain medical evidence from all treating sources
for a period up to 12 months prior to the date of application and
cover the timeframe for which the disability determination is
being sought. Be sure to send the treating physician a Functional
Capacity Assessment form (page 2 of the DSS-486T).
As medical evidence is received, a disability package is created
consisting of:
o The completed DSS-1151
o Applicable portions of the DSS-486T, signed by a Medical
Doctor or qualified Psychologist (as applicable)
o All requested medical evidence
Complete a MBI-WPD Transmittal sheet with 2 copies placed on the
front of the disability packet.
Mail the complete disability packet to:
MBI-WPD Coordinator
Division of Consumer and Local District Relations
NYS Department of Health
Office of Medicaid Management
One Commerce Plaza, Room 728
Albany, New York 12260
When the disability determination is complete, the State Disability
Review Team in Albany will send a copy of the Disability Review Team
Certificate (DSS-639), along with a copy of the submitted disability
packet, to the local district. A DSS-4141 “Notice of Medical Assistance
Disability Determination” will be included with the completed disability
determination package that is returned to the LDSS. The State
Disability Review Team will complete the determination portion of the
form. Local district staff is responsible for filling in districtspecific information, including county name, address telephone number.
Note: The local district must fill in a telephone number that the
applicant may call to request a copy of the DSS-639 disability
determination decision. The local district must send a copy of the
completed DSS-4141 form to the applicant and retain a copy of the
completed notice in the client’s record.
Consultative Exams
If an applicant does not have a medical treating source or the treating
source is unwilling or unable to provide necessary medical information
for a disability determination, the local district must arrange a
consultative exam. Regulations at 18NYCRR 360-5.5 provide that the
local district must pay for the cost of such examinations, consultations
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 15
and tests required by the disability review team when they indicate that
more information is needed. These costs are subject to reimbursement as
an administrative expense, whether or not the applicant is subsequently
determined disabled. Federal financial participation shall be claimed
for such expenditure even if the client is subsequently determined not
disabled. However, as previously stated, there are no local
administrative costs for the MBI-WPD program.
Continuing Disability Review
All Continuing Disability Reviews (CDR) for all working individuals,
regardless of their participation in the MBI-WPD program, must now be
performed by the State Disability Review Team, even if the local
district performs its own disability determinations. This applies to
all such individuals, even those not currently participating in the MBIWPD program.
The local district prepares the CDR packet by contacting all known
medical providers for current medical evidence. District workers will
use the existing Disability Review Team Certificate (DSS-639) and the
Disability Interview (DSS-1151) form as a guide in preparing the
continuing disability review packet. Once the new medical evidence is
received, the CDR packet is sent to the State Disability Review Team in
Albany, MBI-WPD Coordinator (see instructions and address under “New
Disability Determinations” section above).
Upon completion of the continuing disability review, the State
Disability Review Team will send the district a copy of the Disability
Review Team Certificate (DSS-639), the medical evidence package and the
DSS-4141. The DSS-4141 will be completed by the LDSS and sent to the
recipient. The LDSS retains a copy of the DSS-4141 in the client
record.
Note: New disability determinations for A/Rs who are not working and/or
not applying for the MBI-WPD program and Continuing Disability Reviews
for recipients who are not working will continue to be performed by the
responsible (State or local) review team.
Assignment of Applicant to Basic or Medical Improvement MBI Group
The only instance in which the local district may assign an individual
to the MBI-WPD Basic Group is if a new applicant is in an existing
approval period for disability certification at the time of application.
If, at the time of new application, the individual is in receipt of SSDI
or if the individual is in a disability approval period that was
determined by the State or Local Disability Review Team, the individual
may be placed in the MBI-WPD Basic Group by the local district if
otherwise eligible for the program and working. In all other instances,
the State Disability Review Team assigns the MBI group for which the A/R
is eligible. If an applicant is not in receipt of SSDI benefits or is
not currently determined disabled or is in the MBI-WPD program and a CDR
is indicated, the disability determination must be made by the State
Disability Review Team in Albany. The State Disability Review Team will
notify the local district if the applicant is to be considered for
eligibility in the Medical Improvement Group.
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
D. Financial Requirements:
Page No. 16
Income and Resources
Regular SSI-related budgeting rules will be used to determine an
individual’s net available monthly income and countable resources. This
includes applying all SSI-related income and resource disregards and
allocation and deeming, when applicable. Local district staff is
reminded that as for all SSI-related cases, the individual’s non-medical
Impairment Related Work Expenses (IRWEs) may be disregarded (see
Medicaid Reference Guide pages 195 –198 and the December 10, 2003 videoteleconference on IRWEs and PASS). We anticipate that some of the
applicants will be seeking Plans to Achieve Self Support (PASS)
accounts, which are disregarded for purposes of determining SSI-related
A/R’s Medicaid eligibility (see Medicaid Reference Guide pages 178-179,
200-201 and 320 and the December 10, 2003 video-teleconference on IRWEs
and PASS).
Procedures for establishing household size for MBI-WPD will be the same
as for regular SSI-related budgeting. The individual’s net available
income, after applying all disregards and exemptions, will be compared
to 150% or 250% of the FPL for a household of one or two. If an A/R’s
income exceeds 250% of the FPL, the A/R is determined ineligible for the
MBI-WPD program. If an A/R’s net available monthly income is at or
below 250% of the FPL and countable resources are at or below the
$10,000 resource standard (regardless of household size), the A/R will
be financially eligible for Medicaid coverage under the MBI-WPD program.
A/Rs cannot spenddown income to 250% of the FPL and qualify for coverage
under the MBI-WPD program. Additionally, countable resources must be at
or below the $10,000 resource standard as of the first of the month in
which coverage is sought.
E. Social Security Administration Programs:
(SSI) 1619(a) and 1619(b) Programs
Supplemental Security Income
The LDSS is reminded that if an individual is active on a Supplemental
Security Income (SSI) case, the individual receives automatic Medicaid
and is not eligible for the MBI-WPD program. If the individual is
notified by the Social Security Administration that their SSI case will
terminate, that individual must have a separate Medicaid eligibility
determination, including a determination of eligibility under the MBIWPD program. Medicaid coverage must continue until a separate
eligibility determination for Medicaid is made. All criteria must be
met for the MBI-WPD program in order for an individual to be found
eligible for the program. The most likely scenario will be that the
individual has been participating in SSA’s 1619(b) program and has
reached the income threshold for participation in that program. Another
likely scenario would be one in which the individual exceeds the
resources amount allowed by SSI. The LDSS is reminded that the
resources level for the MBI-WPD program is $10,000 for an individual or
a couple.
F. Medicaid Managed Care
Medicaid Managed Care is a voluntary option only for those MBI-WPD
recipients who are income eligible under 150% of the FPL. Pursuant to
statute, all other MBI-WPD recipients are excluded from managed care.
In districts where enrollment in a managed care plan is mandatory,
individuals in the MBI-WPD program cannot be required to enroll. It
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 17
should be noted that individuals in receipt of Medicare, regardless of
income level, are excluded from enrollment in managed care at this time.
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 18
G. Premium Payments
MBI-WPD participants with net (earned and unearned) income between 150%
and 250% of the FPL shall be required to pay a monthly premium for
Medicaid coverage based on a percentage of their earned and unearned
income. However, due to the unavailability of an automated premium
collection and tracking system for the MBI-WPD program, a moratorium
exists on premium collection until the automated system is completed.
H. Co-Pays
All applicable Medicaid co-pays continue to apply for MBI-WPD program
participants. Co-pays apply in addition to any premium payment the
participant makes.
I. Notices
The LDSS is to provide the individual with a copy of the “Explanation of
the MBI-WPD Program” (see Attachment I of this ADM). CNS and manual
notices have been developed. Manual Acceptance notices in English and
Spanish are Attachments V and VI of this ADM. These manual notices must
be used until further instructions are issued. CNS notices are in
development and instructions for use will be forthcoming.
J. Reimbursement of Spenddown
Individuals transitioned from spenddown to the MBI-WPD program are
eligible for reimbursement of any spenddown amount paid in the three
months prior to the MBI-WPD application if the eligibility determination
indicates that the individual was eligible for the MBI-WPD program
during that retroactive period. The usual procedures for retroactive
coverage apply.
K. Third Party Health Insurance
All Third Party Health Insurance rules that are used for Medicaid apply
for the MBI-WPD program.
L. MBI-WPD Recertification/Renewal
MBI-WPD recertifications/renewals must be carefully screened to insure
that all MBI-WPD eligibility requirements are met. Current employment
must be verified. District workers must see current pay stubs or other
acceptable verification of work (per the MRG) or the case cannot be
recertified for the MBI-WPD program. The district worker must also
attend to the applicant’s current age and remember to discuss the age
requirement if the individual’s 65th birthday will be attained within 12
months from recertification. The authorization period must be adjusted
accordingly. Disability certification must also be verified. If the
expiration date on the certification falls within 12 months of the date
of recertification, a Continuing Disability Review (CDR) is necessary
and a disability packet must be initiated for review by the State
Disability Review Team in Albany. Individuals recertifying/renewing for
the MBI-WPD program must continue to be income and resource eligible.
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 19
M. Co-Op Cases
There is no longer a need for separation of an MBI-WPD individual from
other members of the household on a co-op case. Use of the appropriate
Individual Category Code (see Systems Implications) when performing data
entry for an MBI-WPD individual allows identification of MBI-WPD
participants for DOH OMM federal reporting purposes. Therefore, it is
no longer imperative that the SSI-related budget be stored separately
from any other budget(s) for the household.
N. LDSS Reporting Requirements
Due to federal reporting requirements, select MBI-WPD data must be
reported monthly by all local districts. Local district staff must use
the MBI-WPD Monthly Report form (see Attachment VII) to report necessary
data. The report form must be received in the Albany Central Office by
the fifth day of every month and cover data for the previous month. The
form may be submitted via U.S. mail to the MBI-WPD Coordinator or by email to:
[email protected]
V. SYSTEMS IMPLICATIONS
A. New York City
New York City systems instructions will follow under separate cover.
B. Upstate
Systems codes and edits which were modified to support the interim
implementation of the MBI-WPD program are available to LDSS. A
description of the items below can be found in the WMS/CNS Coordinator
Letter and the MBL transmittal that we issued that describes the July
21, 2003 WMS migration of the MBI-WPD program.
Note: In the near future, Resource Attestation codes will apply for the
MBI-WPD program. A separate Administrative Directive will be issued to
address resource attestation.
1. WMS Changes
A.
Effective with the July 21, 2003 Migration
Individual Categorical Codes
Two new Individual Categorical Codes have been added for
identification and Federal/State/Local claiming purposes:
70 Medicaid Buy-In – Disabled Basic Group
71 Medicaid Buy-In – Medically Improved
Codes 70 and 71 are allowed in Case Type 20 only.
If the Individual Categorical Code is 70 or 71, the Medicaid Coverage
Code must be 01, 10 or 30.
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 20
If the Individual Categorical Code is 70 or 71, the individual must
be between 16 and 64 years of age.
Restriction/Exception Codes
Two Restriction/Exemption codes for Managed Care will apply:
90 Managed Care Excluded will be used for those individuals with a
net income between 150% and 250% FPL.
91 Managed Care Exempt will be used for those individuals with a net
income that is below 150% FPL who choose not to be in managed care.
Corresponding AID Categories
Two AID category codes apply:
82 Medicaid Buy-In Disabled Basic Group
83 Medicaid Buy-In Medically Improved Group
These AID Categories have been added for reporting purposes.
2. MBL Implications
Effective for MBL budgets with a From Date of July 1, 2003 or after,
two new EEC Codes are available for the MBI-WPD program:
“V” – MBI-WPD(SSI–related budgeting prior to MBI-WPD)
“W” – MBI-WPD(MBI budget only)
The new EEC codes are valid for Budget Types 04, 05 and 06. In
addition, a new field entitled “PASS” is available to enter income
that is to be disregarded in accordance with an approved Plan for
Achieving Self-Support.
When an EEC Code of V or W is entered, the SSI-Related Total Net
Income minus PASS amount is used to calculate eligibility for the
MBI-WPD program. The FPL table used is based on the Living
Arrangement Codes of 1 or 2 (not number in case) and whether a non
SSI-related spouse has sufficient income remaining after allocation
to any non-disabled children in the household.
MBI-WPD total net income after applying all SSI-related income
disregards is compared to 150% of the FPL and 250% of the FPL. The
second EEC screen will display the Net Income and a Medicaid Buy-In
section with one of the following messages:
Eligible
Eligible
Ineligible Income
Ineligible Resources
Ineligible Income/Resources
For an EEC of
150%
250%
250%
250%
$
$
$
$
$
Amount
Amount
Amount
10,000
Amount/$10,000
“V” or “W”, the Resource test is $10,000.
Date:
July 20, 2004
Trans. No.
04 OMM/ADM-5
Page No. 21
3. CNS Changes
Numerous additions to the CNS Denial, Closing and Undercare codes
were implemented to accommodate the MBI-WPD program. The notices are
available and may be found in the WMS/CNS Coordinator Letter and the
MBL transmittal that were issued to describe the July 2003 WMS
migration of the MBI-WPD program.
VI.
EFFECTIVE DATE
July 1, 2004
______________________________________
Kathryn Kuhmerker, Deputy Commissioner
Office of Medicaid Management
Attachment I
Explanation of the Medicaid Buy-In Program
For Working People with Disabilities (MBI-WPD)
The MBI-WPD program offers people with disabilities who are working the
chance to buy Medicaid health care coverage. The Medicaid Buy-In program
works much like any insurance program. Currently, no premium will be charged
for this coverage, however, in the future you may be asked to pay a monthly
premium. The amount of your premium will be based on your income.
To qualify for the Medicaid Buy-In program, you must:
• Be certified disabled by either the Social Security Administration (SSA)
or State or County Medical Review Team
• Live in New York State
• Be at least 16 but under 65 years of age, and be a U.S. Citizen, a
National, a Native American or an Immigrant with satisfactory
immigration status
• Work in a paid position for which all applicable State and Federal
income and payroll taxes are paid
• Meet the income and resource limits (see below)
• Pay a premium, if required
If you have applied for Medical Assistance, the local department of social
services worker will tell you if you meet the eligibility requirements for full
Medicaid coverage under the MBI-WPD program. Participation in this program is
voluntary.
Budgeting
Special budgeting rules (called methodology) are used to figure the amount of
your income and resources that will be counted to decide if you are eligible for
the MBI-WPD program. We will not count all of your income and resources. See
the Income and Resources sections below for an explanation.
Income
Because of the special budgeting rules that are used, the amount of your
income that is counted may be considerably less than your gross income.
Income is defined as anything a person receives that can be used to buy
food, clothing or shelter. All of your income (earned and unearned) will be
considered. If your spouse is not disabled, his/her income may also be
considered. Examples of earned income are wages, salary, and
compensation for work for which financial compensation is received and
all applicable State and Federal income and payroll taxes are paid.
Examples of unearned income are Social Security disability or retirement
benefits, interest, or dividends. The income that is counted after the
special budgeting rules are applied is called your net income. Under the
MBI-WPD program, if your net income is less than 150% of the FPL, you
will receive full Medicaid coverage without paying a premium. If your net
income is equal to or above 150% of the Federal Poverty Level (FPL), you
will have to pay a premium for the coverage. If your net income is above
250% of the FPL, you will be determined ineligible for Medicaid under this
program.
A premium payment will not be required at this time. However, in the
future New York State Medicaid may implement a premium payment
if your net income is between 150% and 250% of the Federal Poverty
Level. You will be notified when the premium payment requirement
becomes effective.
If you already get Medicaid at no cost because you qualify through
another program (such as persons receiving SSI, or those in the 1619 (a)
or (b) program) you will not be considered for Medicaid under the MBIWPD program. If you are receiving Medicaid coverage with a spenddown,
you will have the choice of staying on the spenddown program or
switching to the MBI-WPD program.
Resource Limits
The amount of resources a person has is also used to decide if a person
is eligible for the MBI-WPD program. A resource is anything a person
owns that can be converted to cash to purchase food, clothing or shelter.
Examples of resources include checking or savings accounts, real estate,
cars, boats, or other vehicles, stocks, and bonds. To be eligible for the
Medicaid Buy-In program, a person may have countable resources up to
$10,000. However, because a special budget is used, certain resources
are not counted. See the next section for items that might not be counted.
Exemptions, Exclusions, Deductions, and Disregards
The words: exemptions, exclusions, deductions, and disregards may all be
used to describe amounts of money or values of items that are subtracted
from a person’s total income to figure the person’s countable income and
resources. Some examples of these include $20.00 deducted from
unearned income, $65.00 deducted from earned income (plus ½ the
remainder deducted from earned income), one automobile not counted as
a resource, etc.
NOTE:
• Co-pays: Some Medicaid services have a small co-payment. These
services may be provided using your Medicaid card or through your
managed care plan if you are enrolled in managed care. You will not have
a co-pay if you are in a managed care plan.
• Managed Care: Only applicants with an income that is below 150% of the
Federal Poverty Level are eligible to participate in a managed care plan
through the MBI-WPD program.
• You are required to tell us if your income changes. You may call your
local department of social services.
ATTACHMENT II
MEDICAID BUY-IN FOR WORKING PEOPLE WITH DISABILITIES (MBI-WPD)
GRACE PERIOD REQUEST FORM
NAME:
_________________________________________________________________
ADDRESS:
_________________________________________________________________
_________________________________________________________________
PHONE NUMBER:
__________________
DATE OF BIRTH:
________________
COUNTY:
__________________
SOCIAL SECURITY #: _________________
I AM REQUESTING A GRACE PERIOD FOR CONTINUED PARTICIPATION IN THE MBI-WPD FOR THE FOLLOWING
REASON:
CHANGE IN MEDICAL CONDITION: (medical verification needed)
Verification Attached (physician’s statement)
Date of Last Day Worked: ___________
JOB LOSS (through no fault of the participant)
_____ This is a temporary layoff. My anticipated return date is ______________.
_____ I am actively seeking new employment.
Verification Attached (e.g., layoff notice, statement from Department of Labor, VESID, etc.)
Please Explain: _________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Date of Last Day Worked: ____________
I certify, under penalty of perjury, that the information I have provided on this request form is true and complete to the best of my
knowledge.
________________________________________
Print Full Name
________________________________________
Signature of Application
______________________
Date
-------------------------------------------------------------------------------------------------------------------------------------------To be Completed by the Local District Social Services Office
LDSS Contact: ____________________________________
REQUEST APPROVED
Date: _____________
REQUEST DENIED
Date: _____________
Phone #: ___________________________
Grace Period: __________ to ___________
Reason for Denial: ___________________________________________________________________________
___________________________________________________________________________________________
_________________________________
Signature of LDSS Contact
____________________
Date
MBI-WPD GRACE PERIOD
INSTRUCTIONS
What Are Grace Periods?
A grace period is a time period during which MBI-WPD program participant is not working but remains eligible for the program.
Two types of grace periods may be granted:
•
Medical Reasons: a grace period of up to six months will be allowed if, for medical reasons, the MBI-WPD participant is
unable to continue working. Medical verification will be required. When an applicant requests this type of grace period,
LDSS must request medical verification.
•
Grace Period for Job Loss: a grace period of up to six months will be allowed if, no fault of the participant, job loss is
suffered, i.e., due to layoff, etc. Verification is required. Districts must verify that the recipient is reasonably expected to
return to employment, for example, a temporary layoff, or that the recipient is actively seeking new employment.
Note: MBI-WPD participants reporting job loss due to non-medical reasons should be referred to One-Stop Centers,
Vocational and Educational Services for Individuals with Disabilities (VESID) and Benefits Planning Assistance and
Outreach (BPA&O) services as applicable, so that assistance with employment may be sought prior to loss of eligibility in
the program.
`
How Do I Go About Getting a Grace Period?
A MBI-WPD participant must complete a grace period request on the opposite side of this form. The completed form, along with the
required documentation must be submitted to your Local District Social Services (LDSS) office.
How Often Can I Have a Grace Period?
Recipients may be granted multiple grace periods during a 12-month period. However, in no event may the sum of the grace periods
exceed six months in the 12-month period.
What Kind of Documentation Do I Need?
When applying for a Change in Medical Condition Grace Period, a physician’s statement is required which contains the current health
problem, treatment and the anticipated amount of time you will be out of work.
When applying for a Job Loss Grace Period, verification is also required. Acceptable forms of verification include layoff notice,
statement from Department of Labor, VESID, etc.
How Will I Know if My Grace Period is Approved?
Your LDSS office will send you a letter informing you of your approval and the period of time authorized. Remember, the sum of
your grace periods cannot exceed six months in a 12-month period.
What Happens When I Return to Work?
You should immediately notify your LDSS office of your return to work. Unless you inform the LDSS office of your return to work,
your grace period continues throughout the approved period. This is important because the sum of the grace periods cannot exceed six
months in a 12-month period.
Will My Grace Period Affect My Premium Payments?
Premium payments are calculated on the applicant’s net (earned and unearned) income between 150% and 250% of the FPL. You
must notify your LDSS office immediately of any change in income. The LDSS office will use this information to re-calculate your
premium payments.
Attachment III
MBI-WPD
Sample Grace Period Letter
For
Medical Condition
Address/Letterhead
Date
Dear ________:
This letter will confirm the approval of your request for a grace period in the Medicaid
Buy-In program for Working People with Disabilities (MBI-WPD) due to a change in your
medical condition. This grace period is effective ______ through ______. Your
participation in the MBI-WPD program means that your Medicaid coverage will not be
interrupted during this grace period.
When there is again a change in your medical condition such that you can return to
work, you must notify the local Department of Social Services in writing and submit
verification of employment, i.e. a copy of your first pay stub. At that time, you will no
longer be in a grace period as you will, once again, be considered an actively employed
participant in the MBI-WPD program.
If you are unable to return to work by ______, and require an extension of this grace
period, you will be required to request the extension in writing and document your
medical condition with a letter from your physician. Remember that for the MBI-WPD
program, no more than six months grace period may be allowed in a twelve month
period.
Please contact me if you have any further questions.
Sincerely,
Signature
Attachment IV
MBI-WPD
Sample Grace Period Letter
For
Job Loss
Address/letterhead
Dear ________:
This letter will confirm the approval of your request for a grace period in the Medicaid
Buy-In program for Working People with Disabilities (MBI-WPD) due to job loss. This
grace period is effective ______ through ______. Your participation in the MBI-WPD
program means that your Medicaid coverage will not be interrupted during this grace
period.
Once you have a new job, you must notify the local Department of Social Services in
writing and submit verification of employment, i.e. a copy of your first pay stub. At that
time, you will no longer be in a grace period as you will, once again, be considered an
actively employed participant in the MBI-WPD program.
If you do not obtain a job by ______, and require an extension of this grace period,
you will be required to request the extension in writing and document your efforts to
actively seek employment during the time of the current grace period. Documentation of
employment-seeking means you must keep a job interview record containing the
following:
1. The date of each job interview that you have attended.
2. The name and title of the individual who conducted the interview and the address
and phone number of the business or agency where the interviews took place.
3. The outcome of each interview (offered a job, or were not offered a job).
4. If you declined a job offer, the reason you declined.
5. If a VESID counselor is assisting you in your job-seeking efforts, written
verification from the VESID counselor will be accepted as supportive
documentation, as long as it contains the information in your job interview record.
We wish you luck in your efforts to obtain employment.
Sincerely,
Signature
Attachment V
NOTICE OF ACCEPTANCE OF YOUR MEDICAL ASSISTANCE APPLICATION
(MEDICAID BUY-IN PROGRAM FOR WORKING PEOPLE WITH DISABILITIES)
Notice Date
Name and Address of Agency/Center or District Office
_________________
Case Number
CIN Number
Case Name and Address
GENERAL TELEPHONE NO. FOR QUESTIONS OR
HELP:
_______________
OR
Agency Conference
Fair Hearing Information
and Assistance
Worker No.
Office No.
OCP
Unit No.
MBI-WPD
_________________
(800) 342-3334
Record Access
_________________
Legal Assistance
_________________
Worker Name
Telephone No.
We will ACCEPT the Medical Assistance Application dated _________________ for the Medicaid Buy-In Program for
Working People with Disabilities (MBI-WPD) effective _________________, for _________________.
Please review the Medical Assistance Utilization Threshold Fact Sheet, found in the Medical Assistance section of the booklet “LDSS-4148B: “What
You Should Know About Social Services Programs”. The Fact Sheet explains any services limitations. The LDSS-4148B was given to you when you
applied for assistance.
This is because your net income (gross income less Medical Assistance deductions) of _________________ is at or below
the Medicaid Buy-In Program for Working People with Disabilities (MBI-WPD) income limit of $ _________________
(250% of the Federal Poverty Level) and your countable resources of _________________ are at or below the resource
limit of $10,000.
This means that you will be enrolled in the New York State MBI-WPD program, which will provide you with Medical
Assistance coverage as long as you are:
• certified disabled; and
• are working; and
• are at least 16 but less than 65 years of age; and
• have net income at or below 250% of the Federal Poverty Level (FPL); and
• have resources at or below $10,000; and
• are meeting your premium payment obligations (if required).
NOTE: A PREMIUM PAYMENT WILL NOT BE REQUIRED AT THIS TIME. HOWEVER, IN 2005 NEW YORK
STATE MEDICAID WILL IMPLEMENT A PREMIUM PAYMENT COLLECTION SYSTEM. IF YOUR NET INCOME
IS BETWEEN 150% AND 250% OF THE FEDERAL POVERTY LEVEL YOU WILL BE REQUIRED TO PAY A
PREMIUM. WHEN THE PREMIUM PAYMENT REQUIREMENT BECOMES EFFECTIVE YOU WILL BE
NOTIFIED OF THE AMOUNT OF THE PREMIUM REQUIRED.
Since you requested that we determine your Medicaid eligibility for all covered care and services
INCLUDING community-based long-term care BUT NOT nursing facility services, we did not review your resources
for the past 36 months (60 months for trusts) and you will not be covered for the following nursing facility services:
• Nursing home care that is expected to last at least 30 days; or
• Nursing home care provided in a hospital; or
• Home and community based waiver services; or
• Hospice in a nursing home; or
• Managed long-term care in a nursing home.
If you need nursing facility services, notify your local Department of Social Services. They will then arrange to
review your resources for the past 36 months (60 months for trusts) to find out if you are eligible for Medicaid
coverage for these services.
We have enclosed a budget worksheet(s) so that you can see how we determined your eligibility for benefits.
The LAW(S) AND/OR REGULATION(S) which allows us to do this is Sections 366(1)(a)(12) and 367-a(12)of the
Social Services Law.
REGULATIONS REQUIRE THAT YOU IMMEDIATELY NOTIFY THIS DEPARTMENT OF ANY CHANGES IN NEEDS,
RESOURCES, LIVING ARRANGEMENTS OR ADDRESS
YOU HAVE THE RIGHT TO APPEAL THIS DECISION
BE SURE TO READ THE BACK OF THIS NOTICE ON HOW TO APPEAL THIS DECISION
RIGHT TO A CONFERENCE: You may have a conference to review these actions. If you want a conference, you should ask for one as soon as
possible. At the conference, if we discover that we made the wrong decision or if, because of information you provide, we determine to change our decision,
we will take corrective action and give you a new notice. You may ask for a conference by calling us at the number on the first page of this notice or by
sending a written request to us at the address listed at the top of the first page of this notice. This number is used only for asking for a conference. It is not
the way you request a fair hearing. If you ask for a conference you are still entitled to a fair hearing. If you want to have your benefits continue unchanged
(aid continuing) until you get a fair hearing decision, you must request a fair hearing in the way described below. Read below for fair hearing information.
RIGHT TO A FAIR HEARING: If you believe that the above action is wrong, you may request a State fair hearing by:
(1) Telephone: (PLEASE HAVE THIS NOTICE WITH YOU WHEN YOU CALL)
The new Statewide toll-free request number is (800) 342-3334 OR
(2) Fax: Send a copy of this notice to fax no. (518) 473-6735. OR
(3) On-Line: Complete and sending the online request form at: https://www.otda.state.ny.us/oah/oahforms/erequestform.asp OR
http://www.otda.state.ny.us/oah/forms.asp OR
(4) Write: Send a copy of this notice completed, to the Fair Hearing Section, New York State Office of Temporary and
Disability Assistance, P.O. Box 1930, Albany, New York 12201. Please keep a copy for yourself.
I want a fair hearing. The Agency’s action is wrong because:____________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Print Name: __________________________________________________________ Case Number_____________________
Address: _____________________________________________________________Telephone: ______________________
Signature of Client: ____________________________________________________ Date: ___________________________
YOU HAVE 60 DAYS FROM THE DATE OF THIS NOTICE TO REQUEST A FAIR HEARING
If you request a fair hearing, the State will send you a notice informing you of the time and place of the hearing. You have the right to be represented by
legal counsel, a relative, a friend or other person, or to represent yourself. At the hearing you, your attorney or other representative will have the opportunity
to present written and oral evidence to demonstrate why the action should not be taken, as well as an opportunity to question any persons who appear at the
hearing. Also, you have a right to bring witnesses to speak in your favor. You should bring to the hearing any documents such as this notice, paystubs,
receipts, medical bills, heating bills, medical verification, letters, etc. that may be helpful in presenting your case.
CONTINUING YOUR BENEFITS: If you request a fair hearing before the effective date stated in this notice, you will continue to receive your benefits
unchanged until the fair hearing decision is issued. However, if you lose the fair hearing, we may recover the cost of any Medical Assistance benefits that
you should not have received. If you want to avoid this possibility, check the box below to indicate that you do not want your aid continued, and send this
page along with your hearing request. If you do check the box, the action described above will be taken on the effective date listed above.
I agree to have the action taken on my Medical Assistance benefits, as described in this notice, prior to the issuance of the fair hearing decision.
LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid Society or other
legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under “Lawyers” or by calling the
number indicated on the first page of this notice.
ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your case file. If you
call or write to us, we will provide you with free copies of the documents from your file, which we will give to the hearing officer at the fair hearing. Also, if
you call or write to us, we will provide you with free copies of other documents from your file, which you think you may need to prepare for your fair
hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number listed at the top of page 1 of this notice
or write us at the address printed at the top of page 1 of this notice.
If you want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time before
the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed.
INFORMATION: If you want more information about your case, how to ask for a fair hearing, how to see your file, or how to get additional copies of
documents, call us at the telephone numbers listed at the top of page 1 of this notice or write to us at the address printed at the top of page 1 of this notice.
Attachment VI
AVISO DE ACEPTACIÓN DE SU SOLICITUD PARA ASISTENCIA MÉDICA
(PROGRAMA DE COMPRA DE BENEFICIOS DE MEDICAID PARA PERSONAS QUE TRABAJAN Y
ESTÁN INCAPACITADAS)
Nombre y dirección de la agencia/Centro u oficina de
distrito
Fecha del aviso
Número de Caso
Número CIN
Nombre del Caso y Dirección
No. DE TELÉFONO GENERAL PARA HACER
PREGUNTAS O PEDIR AYUDA (518) 473-8887
O
No. de oficina
No. de unidad No. de trabajador(a) de casos
Conferencia con la agencia
Audiencias imparciales
Información y asistencia
(518) 473-8887
(800) 342-3334
Acceso a los archivos
(518) 473-8887
Asistencia Legal
________________
Nombre del trabajador(a)
No. de teléfono
MBI-WPD
ACEPTAREMOS su solicitud para Asistencia Médica de fecha _______________ para el Programa de Compra de Beneficios de Medicaid
para Personas que Trabajan y están Incapacitadas(MBI-WPD) a partir del _______________, para la(s) siguiente(s) persona(s) (nombre/s)
________________________________________.
Favor de revisar la hoja de datos del umbral de utilización del programa de Asistencia Médica que se encuentra en la sección de
Asistencia Médica del folleto LDSS-4148B-SP titulado «Lo que usted debe saber sobre los programas de servicios sociales». Esta
hoja le explica las limitaciones en los tipos de servicios. El folleto LDSS-4148B se le entregó cuando solicitó los servicios de
asistencia.
Esto de debe a que su ingreso neto (ingresos brutos menos las deducciones de Asistencia Médica) por la cantidad de _______________ es
igual o menor que la cantidad límite permitida por el programa de Compra de Beneficios de Medicaid para Personas que Trabajan y están
Incapacitadas (MBI-WPD) cuyo límite es de $______________ (250% del nivel de pobreza según lo establece el gobierno federal) y los
recursos que se tomaron en cuenta por la cantidad de $_______________ sobrepasan o llegan al límite de recursos de $10,000.
Esto significa que usted puede afiliarse al programa del Estado de Nueva York de MBI-WPD, el cual le proporcionará cobertura de
Asistencia Médica siempre y cuando:
•
tenga un reconocimiento médico indicando su incapacidad; y
•
esté trabajando; y
•
tenga por lo menos 16 años de edad pero menos de 65; y
•
tenga ingresos netos menores o igual al 250% del nivel de pobreza según lo establece el gobierno federal (FPL); y
•
tenga recursos igual o menor a una cantidad de $10,000; y
•
cumpla con sus obligaciones en cuanto a los pagos de prima (de ser obligatorios).
TOME NOTA: NO SE LE EXIGE UN PAGO DE PRIMA POR EL MOMENTO. SIN EMBARGO, EN EL 2005 EL ESTADO DE NUEVA
YORK PONDRÁ EN MARCHA UN SISTEMA PARA LA RECOLECCIÓN DE LOS PAGOS DE PRIMA. SI SUS INGRESOS NETOS
ESTÁN ENTRE EL 150% Y EL 250% DEL NIVEL DE POBREZA SEGÚN LO ESTABLECE EL GOBIERNO FEDERAL SE LE EXIGIRÁ
PAGAR UNA PRIMA. CUANDO EL REQUISITO DEL PAGO DE PRIMA ENTRE EN VIGOR SE LE NOTIFICARÁ DE LA CANTIDAD DE
LA PRIMA A PAGAR.
Debido a que usted nos solicitó determinar si reúne las condiciones para recibir todos los cuidados y servicios que cubre Medicaid
INCLUYENDO cuidados a largo plazo proveídos en la comunidad PERO NO los servicios de enfermería en centros de cuidados, no
examinamos sus recursos de los últimos 36 meses (60 meses si se trata de un fideicomiso) y no tendrá cobertura por los siguientes
servicios de enfermería:
• Cuidados de enfermería que se crea tengan una duración de por lo menos 30 días; o
• Cuidados de enfermería provistos en un hospital; o
• Cuidados de hospicio en centro de cuidados de enfermería; o
• Cuidados administrados de salud a largo plazo en un centro de cuidados de enfermería.
Si necesita cuidados de enfermería en un centro, comuníquese con su departamento local de Servicios Sociales. El personal de ese
departamento examinará los recursos de los que ha dispuesto en los últimos 36 meses (60 si se trata de un fideicomiso) para determinar si
reúne las condiciones para que Medicaid cubra estos servicios.
Hemos incluido una hoja(s) de cálculo de presupuesto de manera que usted pueda entender cómo hemos determinado los beneficios para
los cuales usted reúne los requisitos.
La LEGISLACIÓN Y/O REGLAMENTO que nos permite tomar esta decisión es la Sección 366(1)(a)(12) y 367-a(12) de las leyes de
Servicios Sociales.
ATENCIÓN: Las personas que reciben Asistencia Médica podrían reunir los requisitos para recibir un descuento en su servicio telefónico.
Para más información sobre el servicio de Lifeline llame al 1-800-555-5000, la llamada es gratis.
LEGISLACIÓN VIGENTE EXIGE QUE USTED NOTIFIQUE INMEDIATAMENTE A ESTE DEPARTAMENTO DE TODO CAMBIO EN SUS NECESIDADES,
RECURSOS, SITUACIÓN DE VIVIENDA O DIRECCIÓN.
USTED TIENE EL DERECHO DE APELAR ESTA DECISIÓN.
LEA EL REVERSO DE ESTE AVISO PARA MÁS INFORMACIÓN SOBRE CÓMO APELAR ESTA DECISIÓN.
LDSS-4374-S (Rev. 10/03) REVERSO
DERECHO A UNA CONFERENCIA: Usted puede pedir una conferencia para revisar estas acciones. Si desea una conferencia, le sugerimos solicitarla lo
más pronto posible. Si durante la conferencia nos percatamos que nuestra decisión fue errónea, o en base a la información que usted proporcione, decidimos
cambiar nuestra decisión; tomaremos acción correctiva y le proporcionaremos una nueva notificación. Puede solicitar una conferencia llamándonos al
número que aparece en la primera página de esta notificación o enviándonos una solicitud a la dirección que aparece en la parte superior de la misma
página. Este número es solamente para solicitar conferencias y no es la manera de solicitar una audiencia imparcial. Aunque solicite una conferencia,
también tiene el derecho a una audiencia imparcial. Si desea que sus beneficios continúen sin cambios (asistencia ininterrumpida) a la espera de la decisión
de la audiencia imparcial; debe solicitar una audiencia imparcial de la manera que se describe abajo. Lea a continuación la información sobre audiencias
imparciales.
DERECHO A UNA AUDIENCIA IMPARCIAL: Si cree que la decisión antes mencionada es errónea, puede solicitar una audiencia estatal de la
siguiente manera:
(1) Por teléfono: (FAVOR DE TENER A MANO ÉSTA NOTIFICACIÓN CUANDO LLAME)
(800) 342-3334
(2) Por facsímil: Envíe una copia de esta notificación al número de fax (518) 473-6735 ó
(3) Por computadora: Complete y envíe el formulario electrónico de petición en la siguiente dirección de Internet:
https://www.otda.state.ny.us/oah/oahforms/erequestform.asp
ó
http://www.otda.state.ny.us/oah/forms.asp ó
(4) Por escrito: Envíe una copia de esta notificación completamente rellenada a: Fair Hearing Section, New York State Office of Temporary and Disability
Assistance, P.O. Box 1930, Albany, New York 12201. Favor de quedarse con una copia.
Solicito una audiencia imparcial. La decisión de la agencia es errónea porque: _________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Nombre (en letra de molde): ________________________________________________No. de caso_________________
Dirección: _____________________________________________________________Teléfono: ______________________
Firma del cliente: ____________________________________________________ Fecha: ____________________________
USTED TIENE 60 DÍAS A PARTIR DE LA FECHA DE ESTE AVISO PARA SOLICITAR UNA AUDIENCIA IMPARCIAL
Si usted solicita una audiencia imparcial, el Estado le enviará una notificación informándole acerca de la hora y el lugar de la audiencia. Usted tiene el
derecho de ser representado(a) por un abogado, un familiar, un amigo(a) u otra persona, o puede representarse a sí mismo(a). Durante la audiencia, usted, su
abogado u otro representante tendrá la oportunidad de presentar pruebas orales y escritas para demostrar la razón por la cual la acción no debe llevarse a
cabo, así como también la oportunidad de interrogar a toda persona que compadezca en la audiencia. También, tiene el derecho de presentar testigos que
testifiquen en su favor. Se le sugiere presentar en la audiencia documentos tales como: esta notificación, talonarios de pagos salariales, recibos, cuentas
médicas, cuentas de calefacción, verificación médica, cartas, etc., que puedan ayudarle en la presentación de su caso.
CONTINUACIÓN DE SUS BENEFICIOS: Si usted solicita una audiencia imparcial antes de la fecha de vigencia indicada en este aviso; continuará
recibiendo sus beneficios como siempre hasta que se dé a conocer la decisión de la audiencia imparcial. No obstante, si no se decide a su favor en la
decisión de la audiencia imparcial, nos podremos cobrar los beneficios de Asistencia Médica que usted recibió y a los cuales no tenía derecho. Si desea
evitar esta situación, marque la casilla abajo indicando que usted no desea continuar recibiendo ayuda y envíe esta página junto con su petición de
audiencia. Si usted marca la casilla, la acción descrita arriba será adoptada en la fecha de vigencia indicada arriba.
Estoy de acuerdo que se tome la decisión con respecto a mis beneficios de Asistencia Médica, según se describe en esta notificación, antes de darse a
conocer la decisión de la audiencia imparcial.
ASISTENCIA LEGAL: Si usted necesita asistencia legal gratis, puede obtener tal ayuda comunicándose con la Sociedad de Ayuda Legal de su localidad
(Legal Aid Society) u otro grupo legal de abogacía. Usted puede localizar la Sociedad de Ayuda Legal o el grupo de abogacía más cercano buscando en las
Páginas Amarillas bajo “Abogados” (“Lawyers”) o llamando al número que se indica en la primera página de esta notificación.
ACCESO A SU ARCHIVO Y COPIAS DE DOCUMENTOS: Para ayudarle a prepararse para la audiencia, se le otorga el derecho de examinar el
archivo de su caso. Si nos llama por teléfono o nos manda una carta, le proporcionaremos copias gratis de los documentos de su archivo, los mismos que
entregaremos al funcionario de audiencias en la audiencia imparcial. Así mismo, si usted nos llama por teléfono o nos manda una carta, le
proporcionaremos copias gratis de otros documentos de su archivo que usted considere necesarios al prepararse para la audiencia imparcial. Para solicitar
los documentos o para averiguar cómo examinar su archivo, llámenos al número de teléfono para Acceso a archivos que aparece en la parte superior de la
página 1 de esta notificación o escríbanos a la dirección impresa en la parte superior de esa misma página.
Si desea copias de los documentos en su archivo, debe pedirlas con anticipación. Se le entregarán en un plazo razonable antes de la fecha de la audiencia.
Se le envirarán los documentos por correo solamente si usted específicamente lo solicita.
INFORMACIÓN: Si desea más información sobre su caso, cómo solicitar una audiencia imparcial, cómo examinar su archivo o cómo conseguir copias
adicionales de documentos, llámenos a los números de teléfono indicados al comienzo de la página 1 de esta notificación o escríbanos a la dirección
impresa en esa misma página.
Attachment VII
MBI-WPD MONTHLY REPORT
County Name:
____________________________________
County Contact:
____________________________________
Month of Report: ______________________
Phone #: _______________
Date:
_______________
NEW APPLICANTS FOR MBI:
CIN #
Receipt of SSDI
Disability Diagnosis
Yes
No
Mental Physical Combination
Job Title
Grace Period Requested This Month
# Days Available
UNDERCARE:
CIN #
# Days Requested